10-264J Request for Deferment

OMB Control No. 2900-XXXX
Estimated Burden: 10 Minutes
Expiration Date: XXXXX XX, 20XX

READJUSTMENT COUNSELING SERVICE SCHOLARSHIP PROGRAM (RCSSP)

REQUEST FOR DEFERMENT

A participant may request a deferment of obligated service to complete an approved program of advanced clinical training.
This document represents a request from you to delay the start of your Department of Veterans Affairs service obligation.
Return the completed form to:
RCSSP
Readjustment Counseling Service (10RCS)
Department of Veterans Affairs
810 Vermont Ave., NW
Washington, DC 20420.
THE PAPERWORK REDUCTION ACT OF 1995: This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Therefore,
we may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time
expended by all individuals who complete this form will average 10 minutes. This includes the time it will take to follow instructions, gather the necessary facts, and fill out
the form.
PRIVACY ACT NOTICE: The VA is asking you to provide the information on this form under the authority of 38 CFR, sections 17.545 through 17.553 (RCSSP) in
order for VA to determine the applicant's eligibility to receive a scholarship award. VA may disclose the information that you put on the form as permitted by law. VA may
make a "routine use" disclosure of the information for: civil or criminal law enforcement; congressional communications; the collection of money owed to the United
States; litigation in which the United States is a party or has interest; the administration of VA training and scholarship programs, including verification of the applicant's
eligibility to participate; and personnel administration. You do not have to provide this information to VA but, if you do not, VA may be unable to process the applicant's
request for a scholarship. If you give VA a social security number, VA will use it to obtain information relevant to determining whether to grant a scholarship, and to
administer the applicant's scholarship, if awarded. It also may be used for other purposes authorized or required by law.

RCSSP
Participant's Name (Last, First, Middle):

Social Security Number:

Address (Include Street Address, City, State, and ZIP Code):

Phone Number:
Email Address:
Program Start Date
(MM/DD/YYYY):

Type of Residency/Fellowship/Clinical Program
you Wish to Attend:

Length of
Program:

Is your selection for this residency/fellowship/
clinical program through a national match
program?
No
Yes

If yes, Title of the Match Program:

Anticipated Date Available for Service
Obligation (MM/DD/YYYY):
What is the Notification Date
(MM/DD/YYYY)?

Are all match sites/locations that you have applied Name of Accrediting Body:
to accredited by the nationally recognized
accrediting body?
Yes
No
Name and Location of Residency/Fellowship/Clinical Site if Known:

Name, Address and Telephone Number (other than your own) of a Person Through Whom you may Always be Reached:
Name of Secondary Contact (Last, First, Middle):

Phone Number:

Address (Include Street Address, City, State, and ZIP Code):

If you have any questions please contact the Department of Veterans Affairs, Readjustment Counseling Service Clinical Team at
[email protected]

Signature
VA FORM
NOV 2021

10-264J

Date (MM/DD/YYYY)
10RCS

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